Thornwald Home

Inspectors wroteBased on observations, clinical record review, review of call bell audit reports, and resident and staff interviews, it was determined that the facility failed to ensure sufficient staffing was provided to meet resident needs, as evidenced by extended call bell wait times, for four of 13 residents reviewed (Residents 4, 10, 11, and 12).

Inspectors wroteBased on clinical record review, policy review, observations, and resident and staff interviews, it was determined that the facility failed to ensure that resident assessments accurately reflected the resident's status for three of 18 residents reviewed (Residents 4, 12, and 14).

Inspectors wroteBased on facility policy review, personnel file review, and staff interviews, it was determined that the facility failed to ensure that residents were protected from the potential for abuse by failing to verify the standing of professional license prior to hire for two of five personnel files reviewed (Employees 3 and 4). Findings Include:Review of facility policy, titled Admin Freedom from Abuse Policy, read, in part: I. Screening A. To ensure resident safety, UCC Homes will not hire prospective employees with disciplinary action against their licenses or certification, which includes Individuals found guilty of abuse. Prospective employees will undergo screening within the allowable timeframes. The screening process shall include: Verification of active Licensure or Certification with the Department of State and the original display portion of licenses on file, if appliable. [...]

Inspectors wroteBased on facility policy review, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to promote healing of a pressure ulcer for one of one resident reviewed for pressure ulcers (Resident 10).

Inspectors wroteBased on observations, facility documentation, and staff interviews, it was determined that the facility failed to conduct regular inspection of all bed rails/enabler bars as part of a regular maintenance program to identify areas of possible entrapment for one of two residents reviewed with enabler bars (Resident 14).

Inspectors wroteBased on facility policy review, clinical record review, review of facility investigation documentation, and staff interviews, it was determined that the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents, which resulted in actual harm, as evidenced by a 10 cm (centimeter) x 8 cm x 1 cm laceration (a deep cut or tear in the skin) to the right leg, requiring 15 sutures (stitches), for one of seven residents reviewed (Resident 1). [...]

Inspectors wroteBased on personnel training file review, facility policy review, and staff interview, it was determined that the facility failed to implement written policies and procedures by not completing annual abuse training for one of three personnel training records reviewed (Employee 2).

Inspectors wroteBased on facility policy review, clinical record reviews, facility documentation review, and staff interviews, it was determined that the facility failed to report an allegation of abuse in a timely manner for one of four residents reviewed (Resident 1).

Inspectors wroteBased on facility policy review, clinical record reviews, review of facility reported incidents, review of facility documentation, and staff interviews, it was determined that the facility failed to complete thorough investigations of abuse allegations and, therefore, failed to protect the safety of a resident during abuse investigations for one of four residents reviewed (Resident 1).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure residents receive appropriate treatment and services to prevent urinary tract infections in residents with a foley catheter for two of three residents reviewed (Residents 65 and 72).

Inspectors wroteBased on observations, clinical record review, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one of four residents reviewed (Resident 27).

Inspectors wroteBased on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status and failed to notify the physician of a significant weight change for two of 21 residents reviewed (Residents 38 and 79).

Inspectors wroteBased on facility policy review, observations, and staff interviews, it was determined that the facility failed to store food and beverages in accordance with professional standards for food service safety in the main kitchen and two of two dining areas.

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure the resident assessment accurately reflected the resident status for one of 22 residents reviewed (Resident 75). Findings Include: Review of Resident 75's clinical record revealed diagnoses that included obstructive and reflux uropathy (a blockage in the urinary tract that causes trouble urinating), benign prostatic hyperplasia (an enlarged prostate), and chronic kidney disease (a condition characterized by a gradual loss of kidney function). Review of Resident 75's physician orders revealed orders for checking and irrigation of a foley catheter, starting December 14, 2023. Review of Resident 75's care plan revealed a focus area [Resident 75] does have continence issues with a subsection, [Resident 75] uses: Bathroom, pull-ups, foley, with a start date of December 14, 2023. [...]

Inspectors wroteBased on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident's care plan was reviewed and revised to reflect the resident's current status for two of 22 residents reviewed (Residents 57 and 75).

Inspectors wroteBased on review of the clinical records and resident and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards that met the residents needs; and failed to implement resident-directed care and treatment consistent with the resident's physician orders and care plan for two of 22 residents reviewed (Resident 70 and 75).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure physician orders were followed for catheter care for one of two residents reviewed for catheters (Resident 75).